Surgical treatment of rheumatoid arthritis based on EBM

Even though the advancement of pharmacotherapy, the maintenance treatment to keep the function of degenerated and destructed joint on rheumatoid arthritis and the surgical treatment for joint reconstruction are very important to prevent the patients from being bedridden and to keep the quality of life. The adaptation of operation varies among disease stage and site of bone destruction. Missing the chance of operation, it becomes impossible to perform surgical treatment. So it is important to consult with specialist finding proper opportunity.     

Malignant rheumatoid arthritis]

Malignant rheumatoid arthritis (MRA) is a name for rheumatoid arthritis (RA) complicated with systemic vasculitis or other severe extra-articular manifestations, which can cause a fatal outcome. MRA is found in 4-5% of inpatients with RA. The male to female ratio is 1:1.45. Histologically, 3 main types are recognised in rheumatoid vasculitis; RA type (vasculitis with rheumatoid nodule-like appearance), PN type (fibrinoid vasculitis similar to PN), and EA type (endoarteritis obliterans). High titers of rheumatoid factor, immune complexes, hypocomplementemia, hypoproteinemia, decreased choline esterase activity, elevated alkaline phosphatase activity and leukocytosis are characteristic laboratory features of MRA. Recently, it appears that MRA is becoming less and the prognosis is getting better, perhaps due to the advancement in treatment.     

Immunocorrection in rheumatoid arthritis]

The clinical and immunological parameters were compared over time in 125 patients with rheumatoid arthritis subjected to immunocorrection. As a result of the study the drugs and their combinations used are distributed in the following order as regards their efficacy: combined treatment with prospidin and tactivin; prospidin; immunoglobulin therapy with high doses; combined therapy with thymohexin and immunoglobulin (low doses); thymohexin; prodigiosan; immunoglobulin (low doses). The dynamics of cellular immunity did not always correlate with the clinical efficacy of the immunocorrection. No relationship was discovered between the functional activity of natural killers and peripheral macrophages and the dynamics of the clinico-laboratory characteristics. Stimulation of endogenous and con A-induced suppression provided a therapeutic effect only in cases of the induction of both suppression types whereas the combined use of prospidin and tactivin allowed the reduction of the intensity and rate of side effects and maintained functions of peripheral macrophages. Immunocorrection which enabled the decrease of the level of lymphocytes expressing HLA-DR antigens in blood turned out most effective.     

Amyloidosis in rheumatoid arthritis]

Complication of secondary amyloidosis is becoming an important problem in the management of rheumatoid arthritis in Japan, because patients with rheumatoid arthritis, complicated by amyloidosis, have been increasing recently and the prognosis is poor in most cases. Renal and gastrointestinal symptoms are cardinal features of amyloidosis in rheumatoid arthritis, and most of these patients die of renal failure or cachexia, based on gastrointestinal involvement, within several years. Diagnosis in the early stage is recommended for good management of amyloidosis in rheumatoid arthritis, and gastroscopic biopsy appears to be the most available method for early diagnosis of amyloidosis.     

Rehabilitation in rheumatoid arthritis]

In the patient with rheumatoid arthritis, muscle weakness and joint contracture and deformity develop, despite the most carefully directed programs of medical care. At the acute phase of this disease, the immobilization or stabilization of arthritic joints is effective for the improvement of inflammation without risk of contracture. At the chronic phase, the patients should be carefully instructed as to the importance of the joint mobility exercise and muscle strengthening exercise. Finally, we must consider that patients with rheumatoid arthritis suffer not only from painful joints but also from psychological and socio-economical damage.     

Development of new drugs for the treatment of rheumatoid arthritis]

Development of new drugs for the treatment of rheumatoid arthritis (RA) can be classified into two categories: one is modification and improvement of the drugs being used now and the other is development of more effective drugs which are being developed by virtue of progress in immunology and molecular biology. The author describes the present status of the treatment of RA and its future trend: anti-rheumatic and anti-inflammatory drugs which may be developed in the near future, recent progress in prodrugs of NSAID, cytokine antagonists, particularly for IL-1, and more specific immunological approaches to the treatment of RA. It is hoped that these potential anti-rheumatic drugs will be developed in next the 10-20 years.     

Osteoporosis in rheumatoid arthritis]

Rheumatoid arthritis may be associated with generalized, as well as, juxta-articular osteoporosis. To assess the skeletal distribution of bone loss, bone mass was measured in women with rheumatoid arthritis, using single photon absorptiometry and dual energy X-ray absorptiometry. Bone loss was more rapid in the distal metaphyseal region of the radius than in the diaphyseal region. Bone loss in the legs was correlated with gait disturbance and bone loss in the third lumbar vertebra was recognized only in the patients treated with corticosteroids for more than 1 year. These results indicate that rheumatoid arthritis was not universally associated with generalized osteoporosis. Patients treated with corticosteroids are likely to be at risk from generalized osteoporosis.